Nigerian Journal of Paediatrics

Evaluation of the preparedness of the childrens emergency rooms CHER in Southern Nigeria for service delivery

Niger J Paediatr 2017; 44 (2):63 – 67

ORIGINAL

Paul NI

Evaluation of the preparedness

Edelu BO

of the children’s emergency

rooms (CHER) in Southern

Nigeria for service delivery

DOI:http://dx.doi.org/10.4314/njp.v44i2.4

Accepted: 9th February 2017

Abstract : Background: The Chil-

cal and manual suction machines,

dren Emergency Room (CHER) is

ambu bags and nebulizers. How-

Paul NI

(

)

the first point of call for many

ever, none of the centres has func-

Department of Paediatrics,

sick children. A significant pro-

tional manual defibrillator or an

University of Port Harcourt,

portion of childhood and under

Automated External Defibrillator

Nigeria.

five deaths in tertiary institutions

(AED). In 5 (55.6%) of the studied

Email: nsypaul@ yahoo.co.uk

takes place in the CHER. There is

centres, the doctors and nurses

thus need for a high level skilled

have training on emergency triage.

Edelu BO

manpower and infrastructure in

Also 5 (55.6%) centres have doc-

Department of Paediatrics,

the CHER in readiness for service

tors with certification in emer-

University of Nigeria, Enugu

delivery.

gency care, but none of the nurses

Campus, Enugu, Nigeria.

Objective: To assesses the prepar-

in all the centres have any certifi-

edness of the children emergency

cation in emergency care. Three

room in tertiary institutions in

(33.3%) centres had staff trained

southern Nigeria to successful

with skills on the use of AED

management of children present-

while in 4(44.4%) centres they

ing to the emergency rooms.

were skilled on the use of manual

Methods: This study was a cross

defibrillators.

sectional, descriptive multicentre

All the centres have a waiting area

study carried out among nine Ter-

for patients’ relatives but only one

tiary Hospitals in Southern Nige-

(11.1%) has a television installed.

ria. Three tertiary hospitals were

All the CHERs have toilet facili-

randomly selected from each of

ties for patients relatives but only 5

the three Geo political zones

(55.6%) have bathrooms. Running

(South-South, South- East and

water is regularly available in the

South -West) in Southern Nigeria.

toilets of only 4 (44.4%) of the

A structured questionnaire was

centres.

used to collect data about the

Conclusion/Recommendation: We

Children Emergency Rooms in

conclude that limitation abounds

these hospitals. The obtained data

with regards to personnel, high

was entered and analysed using

technology infrastructure, person-

SPSS version 21 and is presented

nel skill and patient friendly infra-

as table.

structure. It is recommended that

Results: All the centres have an

concerted efforts should be made

emergency room. The number of

by the government and all key

doctors in CHER ranged from 7 to

players to make available the nec-

22 while the number of nurses

essary equipment and facilities and

ranged from 10 to 24 persons with

ensure that health personnel ac-

a nurse: bed ratio of 1:3-15.

quire the necessary skills so that

In all the centres, the CHER had a

the standard of practice in our ter-

side laboratory, well stocked

tiary hospitals will be comparable

emergency drug shelf, pulse oxi-

to international best practices.

meters, oxygen cylinders, electri-

Introduction

them have better chance of survival. This is especially

true when the child is presenting with life-threatening

Children, unlike adults are more unlikely to withstand

features such as severe respiratory distress or apnoea,

the effect of certain diseases for prolonged periods.

shock, coma, seizures, severe anaemia or severe dehy-

dration. Studies have shown that many children dying in

Thus, they deserve more immediate attention to enable

the emergency room die from preventable infectious

Result

diseases. Most deaths in children presenting to the emer-

Personnel

gency room occur within the first 24hours of presenta-

tion and many can be prevented by immediate and ef-

All the institutions studied have an emergency room and

fective intervention. Thus, anticipation and adequate

operate a three-shift (morning, afternoon and night) sys-

preparation are key elements to increasing the survival

tem. The number of doctors in CHER ranged from 7 to

rate of these children presenting to the emergency room.

22 comprising of consultants, senior and junior resi-

dents, medical officers as well as intern doctors. How-

Apart from the requirement of adequate number of

ever, only 4 (44.4%) centres have dedicated consultants

highly skilled personnel, the physical structure and

in charge of the emergency room. In all the centres,

equipments like suction machines, nebulizers, oxygen

there are junior residents covering night shift, while in 7

cylinders, cardiac monitors etc play very vital roles in

(77.8%) of the centres senior residents also sleep in.

optimizing the outcome of children presenting to the

(See Table 1)

emergency room. Every emergency room that hopes to

The nine centres have nurses ranging from 10 to 24

achieve substantial success in managing children who

persons working in the emergency rooms. The number

present as emergencies must have basic equipment nec-

of nurses covering each shift range from 1-6 nurses. In

essary for resuscitation, stabilization and diagnosis of

relation to the number of beds, the average number of

the common disorders that present in their environment.

beds per nurse ranges from 3-15, giving a nurse: patient

Staff motivations as well as good co-operation from

ratio of 1:3-15. (Table 1)

sister departments like the blood bank, radiology and

laboratory are very essential to the successful manage-

Personnel skills/certification

ment of children in the emergency situations. This study

thus assesses the preparedness of tertiary institutions in

In 5 (55.6%) of the studied centres, the doctors and

southern Nigeria for successful management of children

nurses have training on emergency triage. Also 5

presenting to the emergency room.

(55.6%) centres have doctors with certification in Emer-

gency Paediatrics. but none of the nurses in all the cen-

tres have any certification in Emergency Paediatrics,

though, in 3 (33.3%) of the centres, the nurses have

Methodology

training on basic life support (BLS) . In 4(44.4%) cen-

tres there were staff skilled on the use of manual defi-

This study was a cross sectional, descriptive multicentre

brillators while 3(33.3%) centres had staff trained with

study carried out among nine Tertiary Hospitals in

skills on the use of AED. (See Table 1)

Southern Nigeria. Ethical approval for the study was

obtained from the University of Port Harcourt Teaching

Infrastructure

Hospital (UPTH) ethical committee. Three tertiary hos-

pitals were randomly selected from each of the three

The number of beds in the emergency rooms ranged

Geo political zones (South-South, South East and South

from 8 to 30 beds with 3(33.3%) centres having twenty

West) in Southern Nigeria. University of Port Harcourt

five or more beds. In 9(100.0%) of the centres, the

Teaching Hospital (UPTH) Port Harcourt, Niger Delta

CHER had a side laboratory, well stocked emergency

University Teaching Hospital (NDUTH) Okolobiri,

drug shelf, pulse oxymeters, oxygen cylinders, electrical

Bayelsa State and Federal Medical Centre (FMC) Irrua

and manual suction machines, nebulizers and ambu

in South-South, University of Nigeria Teaching (UNTH)

bags. However, all (100.0%) the centres had no func-

Enugu, FMC Umuahia and FMC Owerri in South-East,

tional manual defibrillator or an Automated External

Lagos University Teaching Hospital (LUTH), Obafemi

Defibrillator (AED). One (10.1%) Centre has a portable

Awolowo University Teaching Hospital (OAUTH), Ife,

mobile X-ray machine and portable ultrasonography

and Ladoke Akintola University of Technology Teach-

scan machine. Getting an X-ray or ultrasound done for a

ing Hospital (LTH), Osogbo, Osun state in South-West.

child takes over 2hrs in 4 (44.4%) of the nine institu-

tions, less than 2 hours in 2(22.2%) and within an hour

A questionnaire was used to collect data about the Chil-

in the remaining 3(33.3%) institutions. (See Table 1)

dren Emergency unit in these hospitals. The question-

naire was divided into 3 sections: Section A contained

Only 2(22.2%) centres have a triage room and piped

information on the number of Personnel (doctors,

oxygen in their CHER. There are no cardiac monitors

nurses, and administration staff), section B had informa-

and endotracheal tubes in 3(33.3%) of the centres. Also,

tion on the skill (ability to use cardiac monitors, defibril-

3(33.3%) centres have a pharmacy that is dedicated to

lators) and certification of the Personnel (certifications

their children emergency room, while 4 (44.4%) centres

in Emergency Paediatrics, BLS, PALS). section C con-

have a resuscitation room. (See Table 1)

tained information on available infrastructure (as shown

All the centres have a waiting area for patients’ relatives

in the results). The obtained data was entered and ana-

but only one (11.1%) has a television installed. All the

lysed using SPSS version 21 and is presented as prose

CHERs have toilet facilities for patients relatives but

and table.

only 5 (55.6%) have bathrooms. Running water is

regularly available in the toilets of only 4 (44.4%) of the

centres. (see Table 1)

Table 1: Summary of the findings in the 9 tertiary hospitals evaluated

Hospital

Total number of Doctors that work in CHER

Total number of nurses working in CHER

Number of nurses per shift

2-4

4-6

2-4

2-6

1-3

2-4

2-3

Have consultants heading the emergency unit

Staff trained on emergency triage

Availability of a triage room

Availability of resuscitation room

Total number of beds

Availability of a side laboratory

A dedicated pharmacy

Stocked emergency drug shelf

Availability of cardiac monitors

Availability of pulse oxymeters

Availability of functional AED

Staff trained on use of AED

Availability of functional defibrillator

Staff trained on use of defibrillator

Availability of functional ECG machine

Emergency ward piped with oxygen

Regular supply of oxygen in cylinders

Availability of oxygen concentrators

Availability of suction machines

Ambu bag

Endotracheal tubes

Availability of nebulizer units

Portable X-ray and ultrasound machines

Time to availability of screened blood *

Dedicated phone for communication

Y – Yes, N – No , * - In hours

vironment where many actions are time dependent and

therefore requires better experience.

4-6

Discussion

Only 44.4% of the centres have dedicated consultants in

charge of the CHER and 55.6% of the centres have con-

This study has shown that there are available Children

sultants with certification in emergency Paediatrics. The

Emergency Rooms (CHER) in the tertiary health institu-

2009 American Academy of Paediatrics (AAP) guide-

tions in southern Nigeria to cater for the needs of chil-

lines for preparedness to treat children in the Emergency

dren who present with emergencies in this region. The

Department identified the designation of a coordinator

three shift system operated by the CHER and the avail-

for Paediatric emergency care as an important first step

ability of twenty hour service in a day is recognized in-

in ensuring readiness for children. Though no such

ternationally and is in tandem with other Emergency

guideline exists in our setting, it is pertinent that each

Depertments. It ensures that services are provided round

centre should have at least one consultant in charge of

the clock and limits care giver burn out since CHER is a

the CHER, considering the significant role of the CHER

very busy area especially at peak periods which is usu-

in Paediatric practice.

ally not predictable.

This nurse: patient ratio of 1: 3-15 in these hospitals fall

The study also shows that in many centres paediatricians

below the internationally recommended standard in the

of senior cadre are available to render services round the

emergency rooms.conclusion The Children Emergency

clock, this is however not the case in 2(22.2%) of the

Room requires a high intensity of service for many con-

centres where senior residents are not available at nights.

ditions, especially during the first hour of treatment;

Junior resident paediatricians, especially those who are

emergency nursing involves patient evaluation, interval

inexperienced may sometimes be overwhelmed and this

assessments, medication administration, procedure assis-

may lead to poor case management. Although, with

tance, point-of-care testing, chart documentation, and

modern communication tool, such as smart phones and

aftercare education.

10, 11

Also, the emergency room is a

tablets this could be minimized, the importance of the

high risk area and trained emergency nurses play a vital

availability of senior doctors in the children emergency

role in medical error reduction in this area. The Ameri-

room on a 24 hour basis need not be overemphasized.

can Academy of Emergency Medicine (AAEM) there-

This must be addressed especially in these days where

fore asserts that, as a guideline for comprehensive, mod-

patients expect and demand quality service. Due to the

erate acuity emergency departments, the maximum

acute and sudden nature of the problems patients present

emergency nurse-to-patient staffing ratio should be 1:3

with to the CHER, stress and anxiety levels are usually

or based on the rate of patient influx such that the rate of

high. Managing the expectations of these patients and

1.25 patients per nurse per hour is not

their families becomes even more challenging in an en-

exceeded. However, this recommendation is still far-

fetched in our setting but striving towards it is a step in

by the government and all key players in Health to make

the right direction.

available these equipment and to train health personnel

Availability of the right mix of physicians, nurses and

on skills to use them so that our standard of practice will

other support staff in the emergency room help to ensure

be comparable to international best practices.

patient satisfaction, emergency room efficiency, cost-

All the centres had well-stocked emergency shelf/tray

effective care and medical-legal safety.

5-7

Emergency

for emergency medications; this is quite encouraging

room staffing involves two key elements: strategic driv-

and the practice must be encouraged and maintained.

ers and tactical drivers. Strategic drivers are the quality

There is also the need for a pharmacy dedicated to the

of care, the level of service you want to deliver and pa-

emergency room to reduce waiting time required to ob-

tient safety while the tactical drivers are patient volume,

tain emergency drugs. This was obtainable in only

acuity, duration of patient stay, admits holds, physician

33.3% of the centres. Alternatively, in centres where

capability and non-physician staffing. Appropriately

pharmacy is shared between CHER and other depart-

configuring staffing patterns based on volume and acu-

ments, there should be pharmacy staff dedicated to

ity is the key to emergency department efficiency, as

emergency room patients.

well as to overall patient satisfaction.

6,7

Having the necessary skill, competence and certification

Each area in the emergency room plays a key part in the

in Emergency Paediatrics among the health team in the

patients’ journey, and the non -availability of a triage and

CHER cannot be over emphasized. That acute care phy-

resuscitation areas in many centres may portend some

sicians and nurses in CHER are not trained in basic skill

danger; this would mean resuscitating patients in areas

as triage as well as on the use of life saving equipment

not designated to do so and would lead to time wastage

such as manual defibrillators and AED is worrisome.

in gathering these equipment when the need arises.

This is so because these skills are used by even para-

Functional areas in the emergency room includes but not

medics at the community hospitals in developed coun-

limited to: waiting/reception area, a triage area, resusci-

tries let alone in tertiary referral centres. While our

tation area, acute treatment area, consultation area, ad-

counterparts in the western world have gone beyond the

junctive areas (x-ray, Short Stay Unit (SSU), allied

three-level triage algorithm system to the five- level

triage system called the emergency severity index,

health, investigations room (point of care testing), Staff/

amenities areas, administrative areas, storage areas,

most emergency room staff are yet to acquire training on

clean preparation and drug preparation room(s), dirty

triage. The welfare of the staff of the CHER should also

utility and disposal areas, patient amenities areas e.g. a

be taken seriously by the authorities and there should be

food storage fridge, toilet (staff and patient including

incentives to help motivate the medical staff that work

for disabled patients) and bathroom/shower facilities and

in CHER just as is done in many hospitals in developed

teaching and research areas.

10,12,13

The triage, resuscita-

countries where there is additional wage/ allowance for

tion and acute treatment areas may be either a re-

emergency room staff.

allocation of existing treatment spaces, or are specifi-

cally purpose built to accommodate a multi-disciplinary

team who are treating patients together. These areas

Conclusion

should be staffed for a rapid turnover of patients with

suitable appropriate outflow areas.

In conclusion, this study has shown that there is consid-

erable availability of some equipment in the Children

Availability of the necessary tool required for patient

Emergency Room, however, limitation abounds with

care varied in the studied centres. While all the centres

regards to personnel, high technology infrastructure,

had the basic tool for the care of many patients who pre-

personnel skill and patient friendly infrastructure. This

sent to the CHER, none had equipment like manual defi-

finding in Southern Nigeria may not be different from

brillator and Automated External Defibrillator (AED).

what obtains in other parts of Nigeria. There is need for

Cardiac monitor was present in 3(33.3%) of the centres,

managers of tertiary health institutions to train and re-

piped oxygen in 2 (22.2%) centres while a portable mo-

train health care workers on necessary skills and to ad-

bile x-ray and ultrasonography scan machine were found

vocate for other sources of funding in the Health sector

in only one centre. The unavailability of these equip-

as Government alone can no longer sustain the burden

ment’s in our emergency rooms is unacceptable because

of health cost.

these are key to the resuscitation, prompt evaluation and

monitoring of varied life threatening complications that

Conflict of Interest: None

present to the CHER on a nearly daily basis. Also, ser-

Funding: None

vices offered in our tertiary centres must go beyond the

mundane as many of these centres have existed for sev-

eral years. This may be partly why there is increasing

Acknowledgement

medical tourism abroad as most often any care beyond

the basic is far reaching. Also, individuals who are

We wish to acknowledge and thank the following

trained or who have trained themselves on skills neces-

persons for their contribution in data collection;

sary to use these equipment loose them fast as the equip-

Dr Wobo Kininyiruchi, Dr Kayode Olamide V

ment are unavailable and so are unable to domesticate or

Dr Ladele Jejelola I, Dr Iregbu Francis

pass on these skills. There is need for concerted efforts

Dr Onyeonoro Ugochukwu, Dr Elusiyan Jerome

References

1. World Health Organisation.

7. Hoy E. Measuring patient ex-

15. Millard, W. B. “The cost of

Guideline: updates on paediat-

periences of care. Bull Am Coll

koi: evidence-based design in

ric emergency triage, assess-

Surg. 2008;93:13 – 6.

emergency medical facilities.”

ment and treatment: care of

8. Farooqi JH. Patient expectation

Annals of Emergency Medi-

critically-ill children Geneva:

of general practitioner care.

cine Sept 2007; 50(3): 267-

World Health Organization

Midd East J Fam Med.

271. 25

2016: 6.

2005;3:1 – 6.

16. Kid-friendly waiting areas in

2. Wammanda RD, Ali FU. Con-

9. American Academy of Pediat-

ED boost satisfaction: video

ditions associated with the Risk

rics. Joint policy statement –

games, bright colors make ED

of death within 24 hours of

guidelines for care of children

visits easier. ED Management

admission in children in Zaria,

in the emergency department.

2003 15(11): 125-126.

Nigeria. Annals of African

Pediatrics. 2009;6:1233 – 1243.

17. Judkins S, “Paediatric Emer-

Medicine 2004; 3:134-7.

10. American Academy of Emer-

gency department design:

3. American College of Emer-

gency Medicine. Emergency

Does it affect staff, patient and

gency Physicians (ACEP).

Nurse-to-Patient ED Staffing

community satisfaction?”

Clinical and Practce Manage-

Ratios. 2013.

Emergency Medicine 2003;

ment, Policy statements: Emer-

11. Australasian College for Emer-

15; 63-67.

gency physician work shift

gency Medicine. Statement on

18. McKay, J. I. “Building the

revised 2010

responsibility for care in Emer-

emergency department of the

4. Taylor D, Kennedy M, Virtue

gency Departments. 2012;

future: philosophical, opera-

E, McDonald G. A multifac-

03:S18

tional, and physical dimen-

eted intervention improves

12. Kesler CJ, “Redesign of a pae-

sions.” Nursing Clinics of

patinet satisfaction and percep-

diatric hospital’s triage and

North America Mar 2002; 37

tions of Emergency Depart-

registration area.” Journal of

(1): 111-122 .

ment care. Int J Qual Health

Emergency Nursing Jun 2007;

Care. 2006;18:238 – 45.

33 (3); 223-227.

Sun BC, Adams J, Orav EJ,

13. Lanoix, R. and J. Golden, “The

Rucker DW, Brennan TA,

facilitated pediatric resuscita-

Burstin HR. Determination of

tion room.”Journal of Emer-

patients satisfaction and will-

gency Medicine 1999;17(2):

ingness to return with Emer-

363-6.

gency care. Ann Emerg Med.

14. Chi CH, Huang CM. Compari-

2000;38:426 – 34.

son of the Emergency Severity

Taylor DM, Wolfe RS, Cam-

Index (ESI) and the Taiwan

eron PA. Analysis of com-

Triage System in predicting

plaints lodged by patients at-

resource utilization. J Formos

tending Victorian hospitals,

Med Assoc. 2006 Aug;105

1997-2001. Med J Aust.

(8):617-25.

2004;181:31 – 5.